Is doxycycline (Doxycycline) safe to use during breastfeeding (nursing)?

Doxycycline Safety During Breastfeeding

Short-term doxycycline use (≤3 weeks) is acceptable during breastfeeding because the drug appears in breast milk at very low concentrations, and calcium in breast milk likely inhibits infant absorption. 1

Primary Recommendation

The American Academy of Dermatology (2025) recommends limiting oral doxycycline to a maximum of 3 weeks without repeating courses for breastfeeding patients requiring systemic antibiotics. 1 This represents the most current high-quality guideline consensus and supersedes older recommendations that listed breastfeeding as an absolute contraindication. 1

Why This Triggers a DUR Flag

Drug Utilization Review (DUR) systems flag doxycycline in nursing mothers because:

• Historical contraindication concerns: Older guidelines (British Thoracic Society 2017) listed breastfeeding as a contraindication, and many pharmacy systems still reference these outdated warnings. 1
• FDA pregnancy category D classification: The FDA label states "a decision should be made whether to discontinue nursing or to discontinue the drug," which triggers automatic alerts despite newer evidence supporting short-term use. 2
• Tetracycline class warnings: Doxycycline belongs to the tetracycline class, which historically caused permanent tooth discoloration in children, leading to blanket restrictions that are now being refined based on newer safety data. 3

Clinical Decision Algorithm for Breastfeeding Mothers

Use doxycycline when:

• Treatment duration will be ≤3 weeks 1
• Alternative safer antibiotics (amoxicillin/clavulanic acid, azithromycin, erythromycin) are inadequate or unavailable 1
• The infant is healthy, full-term, and not premature 1
• The condition is serious or life-threatening and requires doxycycline specifically 2

Avoid doxycycline when:

• Treatment would require >3-4 weeks 1
• Repeated courses would be necessary 1
• The infant is premature, jaundiced, or has conditions that may be affected by the drug 1
• Safer alternatives with stronger safety profiles are available 1

Supporting Safety Evidence

• Low breast milk concentrations: Tetracyclines, including doxycycline, are present only in very low levels in breast milk. 1 One study found tetracycline reached only low peak breast milk concentrations and was undetectable in the serum of breastfeeding infants. 1
• Calcium inhibition of absorption: Calcium in breast milk may inhibit absorption by the infant, further reducing exposure. 1, 2
• American Academy of Pediatrics position: The AAP Committee on Drugs lists tetracycline as "usually compatible with breastfeeding." 1
• Pediatric safety data: Doxycycline is now considered acceptable for short-term use even in children under 8 years of age, which supports its safety profile during breastfeeding. 1

Preferred Alternative Antibiotics

When alternatives are appropriate, consider these first-line options with stronger safety profiles during breastfeeding:

• Amoxicillin/clavulanic acid 1
• Erythromycin or azithromycin 1
• Metronidazole 1
• Clindamycin (use with caution due to potential increased risk of GI side effects in the infant) 1

Critical Caveats and Common Pitfalls

• Do not confuse with other tetracyclines: Tetracycline, minocycline, and oxytetracycline have different safety profiles and remain more problematic. Doxycycline specifically has the most favorable data. 4
• Duration is key: The 3-week maximum is critical. Prolonged or repeated courses should be avoided. 1
• Timing of breastfeeding: Consider breastfeeding prior to medication intake to further limit infant exposure. 5
• Life-threatening conditions: For serious maternal infections, the benefits of doxycycline treatment clearly outweigh potential risks. 1
• Drug interactions: Avoid antacids, calcium, magnesium, aluminum, or iron supplements within 2-3 hours of doxycycline administration, as these impair absorption. 4

Practical Management

When the DUR flag appears, override it if:

• The prescription is for ≤21 days 1
• The clinical indication requires doxycycline specifically 1
• The infant is healthy and full-term 1
• The prescriber has documented consideration of alternatives 1

Contact the prescriber if:

• The prescription exceeds 3-4 weeks duration 1
• Repeated courses are planned 1
• The infant has special risk factors (prematurity, jaundice) 1
• Safer alternatives have not been considered 1